PLB Provider Level Adjustment

To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service

Position
Element
Name
Type
Requirement
Min
Max
Repeat
PLB01
Reference Identification
String (AN)
Mandatory
1
50
1
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB01 is the provider number assigned by the payer.
PLB02
Date
Date (DT)
Mandatory
8
8
1
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
PLB02 is the last day of the provider's fiscal year.
PLB03
Adjustment Identifier
Composite (composite)
Mandatory
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB04
Monetary Amount
Decimal number (R)
Mandatory
1
18
1
Monetary amount
PLB04 is the adjustment amount.
PLB05
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB06
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB06 is the adjustment amount.
PLB07
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB08
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB08 is the adjustment amount.
PLB09
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB10
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB10 is the adjustment amount.
PLB11
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB12
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB12 is the adjustment amount.
PLB13
Adjustment Identifier
Composite (composite)
Conditional
1
01
Adjustment Reason Code
Identifier (ID)
Mandatory
2
2
-
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
02
Reference Identification
String (AN)
Optional
1
50
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
PLB14
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
PLB14 is the adjustment amount.

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